HomeMy WebLinkAbout05 CLAIM #94-03 03-21-94"RENDA
NO. 5
3-21-94
Inter-Corn
'4.._,%
DATE:
MARCH 7, 1994
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT'. PHILIP OLER; CLAIM NO: 94-03; D/L: 11-24-93; DATE
FILED W/CITY: 01-17-94; CARL WARREN FILE NO: S 78055 PRL
After investigation and review it is recommended that the
above-referenced claim be rejected and the City Clerk directed to
give proper notice of the rejection to the claimant and to the
claimant's attorney.
city Attorney
IGR~:(B07~(CL-~.bb)
Enclosure: Copy of Claim
cc: Carl Warren & Co..
Finance Director
City Manager
City of Tustin
CLAIM AGAINST THE CITY OF TusTIN
(For Damages to Persons or Personal Property)
The law provides generally that a claim must be filed with the City Clerk c
the City of Tustin within 6 months after the incident or event occurred. Be
sure your claim is against the City of Tustin, not another public entity.
Where space is insufficient; please use additional paper and identify
information by paragraph number. Completed claims must be mailed or
· delivered to the City Clerk, City of Tustin, 300 Centennial Way, Tustin,
California 92680
---.
WHEN COMPLETING THIS FORM, PLEASE TYPE OR USE BLACK INK
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the 'following claiM' and information
relative to damage to person and/or property:
1. a. NAME OF CLAIMANT: .~l'Ci~ (6.
e. C, ITY/ZIP CODE:., "'
¢)
e. /DATE OF BIRTH: ~-- ~- ~
f... SOCIAL SECURITY NO: -~ ~ - ~
~, ' ,.'
2. Name, telephone and post office address to which claimant desires notice.
to be sent (,if other than ab_ove):
3. This c.l~m is submitted against: "
a. v/ The City of Tustin only.
b. V The following employee(s) o~ the City of Tustin only:
Ce
The City of Tustin and the following employee(s) of the City
of Tustin only:
.
Occurrence or event from which the claim arises:
a. DATE: /[- 2c/ - ~
b. TIME: 5:~9 ~n~
c. PLACE (Exact d specific location):
d. How and un~er what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim cause¢
the ~njur¥ or damage (Use additional paper if necessary)~ . ~ '
/-
I
?
e.
WHAT particul~ .action by the City, or .. employees, caused the
alleged damage ~r injury? - ;'
5. Give a description of the injury, property damage or loss so far known at
the time.eof thi~ claim If_there we~eno injuries, state "no >.n_juries".
6. Give the name~s) of the City emp~oyee(s)~caus~ng the d~.mag.e_or injur~_:
7. Name and address of any other person injured: ~'
10.
8. Name and address o~ Me ownDr~ or .any dame e~propert~: P~~/~ ~ ~o~J
9. Damages claimed:" ~107,
a. ~ount claimed as of the date: ~ ...
b. Estimated amount of-future costs: ~,/6 ~- g~ '~
'c. Total amount claimed: ~ /D~' ~D
d. ~ttach basis for computation of amo~ts claimed (include copies of
all bills, invoices, estimates, etc.
N~e~, 9nd addresses Qf all witnesses, hospitals, doctors, etc. ~'
G · -/7- ~ ~- ~
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! !
(Penal Code Section 72; Insurance Code Section 556.0)
I have read the matters and statements made in the above claim and I know the
same to be true of my own knowledge, except as to those matters stated to be
upon information or belief and as to such matters I believe the same to be
true. I certify under penalty or perjury that the fo.regoing is TRUE AND
CORRECT.
Executed this (~~ day of ~~"
C /
,19 cl~ , at Tustin, California.
--
C. S I GNATURE
B 1: CLFORM
Revised 4/29/91
Authorized Agent t.0~'-~5 O~..O0.~¢ ..._ ~RTOFF,CE P",C6SHEE, O^TE
i
BILLIN. G ADDRESS SERVICE ADDRESS
--
· CCOUNT NAME ACCOUNT NA~E
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ATTN: I ! ! ! ! !
A~
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I I I I t I I ! I I I I I
~DRESS · ~S
~,~ C~, ~ .-- .
~ ~ STA~ ~ ~ STATE ~p . .,.
I f I I I t ~ , I I L~NS~ I I I I ' I I I t I I ! I ~ I ! I I I ! ! ! I I ! I I
. . . , , , I~, ,-, , ~,0,~,
PEmO0 (Ch.ck One) ~ *NNU~ ~R[Y ~ATE(S) OFFICE USE ONLY
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2.
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a Proration
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Oth.
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Othe~ ~ , · : -~ , ~- ;..
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M~HOD OF PAYME~
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SUBTOTAL $
.~ PO: $ g ~
CODE $
~k: $ ~ ~ ..
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' ' - TOTAL $ [ O
.
Jsagr~n~ ~sig~by~~ra~a~Dt~~a~~ AOCEP' ~BY PAGEMART. INC_
~:~.,riber and PageMart, and subscriber agrees to pay all costs, indudir~
)mey and/or collection fee,j incurred in collecting any and all amounts past
~-~lnder this contract. THIS WRmNG REPRESENTS ALL ~ AND
mONS OF THE AGREEMENT BETWEEN PAGEMART AND SUB-
JER AND NO OTHER WAR~IES, EXPRESS OR IMPUED, ARE
,DE. Replacement value for lost or-stolen pager is $ (ini-
i. I waive the Loss Protection Program. (initial). THIS AGREE-
:.NT IS SUBJECTTO ADDITIONAL TERMS AND CONDR'IONS ON THE
VERSE SIDE WHICH SUBSCRIBER ACKNOWLEDGES HAVE BEEN
~,D AND UNDERSTOOD. EPA' /
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.~ckno_ wledges the accuracy of the Information provided and warrants the
busine~ purpose of this application. Cust6rner acknowledges that ongoing
,trice after the term of this agreement will be at the above rates.'
~UBS .C..RIBE~.~, /~. F.
~u~ect to change